Speaker Registration

To register as a speaker for the workshop, the following information must be provided. All fields except Fax, Special Needs, and Presentation Needs are required. When you are finished, click on the Submit Registration Form button.

Personal Information

Salutation
First Name
Last Name
Name Tag
Job Title
Affiliation

Mailing Address

Street
City
State
Zip

Contact Information

Phone
Fax
E-mail

Special Needs

Dietary, Accessibility, Other:

Attendance

I plan to attend these days of the workshop:

	Monday
	Tuesday
	Wednesday

Accomodations

I will need accommodations for:

	Sunday
	Monday
	Tuesday
	Wednesday
	Will not need any accommodations

Transportation

My transportation plans will be to:

	Make my own airline reservations to be reimbursed after the conference
	Call the PSU Pesticide Education office to make airline reservations for me
	Take care of my own transportation (not flying) to be reimbursed after the conference

Presentations Needs

What are your audio/visual and presentation needs?

	Computer
	LCD Projector
	Internet Access
	Flip Charts
	VCR Player
	I will need someone to assist me during my presentation

Other presentation needs (e.g., 8' tables):